Pediatric Hospital Medicine
Top 10 Articles
Elena Aragona
Jamie Librizzi
Objectives
• Summarize important evidence-based
literature relating to pediatric hospital
medicine
• Appraise key PHM articles as they relate to
clinical practice
Apparent Life-Threatening Events
• Patient 1:
5 month old female p/w
ALTE
–
–
–
–
Difficulty catching breath
Face turned red
Lasted ~10 seconds
15min after feed
• Patient 2:
Ex 34 wk 2mo M p/w ALTE
– Hx ALTE 2 wks ago
– Went limp for ~30
seconds
– Not associated with feed
P: In infants presenting with ALTE
I/C: are there any factors
O: that increase risk of subsequent
event?
Management of Apparent Life-Threatening
Events in Infants: A Systematic Review
• Objective: lit review to determine
– Hx and PE features that suggest inc risk of future adverse event
and/or serious dx
– What testing is indicated
• Methods:
– Pertinent articles identified and critically appraised
• 1970-2011
• ALTE in children <24mo
• Results:
– 37 studies identified
• 14 investigated history/PE features
• 31 evaluated diagnostic testing
• All studies observational; none well suited to define w/u or determine
prognosis…
Management of Apparent Life-Threatening
Events in Infants: A Systematic Review
• Results:
– Features associated with future adverse event
and/or serious underlying diagnosis
• Prematurity
• Multiple ALTE
• Suspected child abuse
– Little evidence to support routine testing of all
patients without these risk factors
Meningitis
• ED calls re: 6yo M with fever & headache
found to have CSF pleocytosis, would like to
admit on IV abx for bacterial meningitis r/o
P: In children presenting pleocytosis
I/C: Is there a clinical score to identify
children with high risk for
O: Bacterial Meningitis
JAMA
Clinical Prediction Rule for Identifying Children
with CSF Pleocytosis at Very Low Risk of
Bacterial Meningitis
• Objective:
– To validate clinical prediction rule (Bacterial Meningitis
Score)
• Methods:
– Review records of children with meningitis evaluated in ED
of 20 academic medical centers over 4 years
• Inclusion: 29d – 19yo with ICD9 diagnosis of meningitis
• Exclusion:
– Critical illness, purpura, VP shunt, recent neurosurgery,
immunosuppression, other bacterial infection requiring inpt abx, active
lyme disease, pts with abx within 72h of LP
• Bacterial meningitis: + CSF culture OR CSF pleocytosis with + BCx
OR CSF pleocytosis with + CSF latex agllutination test for bacteria
– N = 2903 (met inclusion criteria, data available)
Clinical Prediction Rule for Identifying Children
with CSF Pleocytosis at Very Low Risk of
Bacterial Meningitis
• Results:
– 1714 low risk patients
• 2 had bacterial meningitis (infants 1-2mo
w E Coli meningitis and UTI; neg UA at
presentation)
– NPV: 99.9%, (95% CI 99.6%-100%)
– 1189 not low risk
• 119 (10%) had bacterial meningitis
• >/= 1 risk factor
– Sensitivity 98.3% (95% CI 94.2%-99.8%)
– Specificity 61.5% (95% CI 59.7%-63.3%
– Use caution when applying to infants
<2mo
• In patients >2mo, >/=1 risk factor had
sensitivity 100%
• Pts <2mo, >/=1 risk factor had sensitivity
92.3%
Blood Cultures
• 20mo M with L thigh cellulitis
– Failed outpt therapy; plan to admit on
clindamycin
• Blood culture?
P: In patients with asthma,
bronchiolitis, pneumonia, SSTI
I: does obtaining blood culture
C: versus no blood culture
O: affect outcomes?
Do We Need This Blood Culture?
Kavita Parikh, Aisha Barber Davis,
Padmaja Pavuluri
Hospital Pediatrics 2014; 4; 78
DOI: 10.1542/hpeds.2013-0053
Do We Need This Blood Culture?
• Objective:
– To assess BCx rates & results for 4 leading
pediatric diagnoses in low-risk patients
• Methods:
– Retrospective cohort
– Review records over 1 y at CNMC
• Inclusion: 6mo – 18yo with bronchiolitis, asthma, SSTI,
CAP
• Exclusion: complex pts
• N = 5159 (1629 inpt, 3530 outpt/ED)
Do We Need This Blood Culture?
• Results:
• BCx
– BCx in 343 pts:
• 21% of inpts, 3% of ED/outpts
–
–
–
–
4% in asthma
15% in bronchiolitis
36% in pna
46% in SSTI
– BCx results
• Asthma – all neg
• Bronchiolitis – all neg
• SSTI – 98% neg or contaminant
– 2 MRSA, 1 GAS
• CAP – 99% neg or contaminant
– 1 strep pneumo, 1 moraxella
– Longer LOS in asthma,
bronchiolitis
– If + (n=5), no change in
management
• Some got rpt BCx though
• ~$100,000 microbiology
costs at our institution
SBI Rule Out in Infant
• 3 wk M with fever
– Well appearing, labs reassuring
– Admitted on IV antibiotics
P: Neonates <1 mo admitted
w/fever for IV antibiotics
I: Discharge at 36h
C: Discharge at 48 hour
O: No missed/untreated SBI
Time to Detection of
Bacterial Cultures in
Infants Aged 0-90 days
Rianna C. Evans and Brian Fine
Hospital Pediatrics 2013;3;97
DOI: 10.152/hpeds.2012-0025
Time to Detection of Bacterial Cultures
in Infants Aged 0-90 days
• Objective: determine if bacterial cultures in
infants <90d would grow pathogenic bacteria in
<36h
• Methods
– Retrospective Chart Review over 3.5y @ single
institution
– Infants 0 to 90 d evaluated in ED or inpt for SBI
– Excluded: indwelling catheters, ‘sick’, rpt cx
• Data Collection
– Manual chart review of all blood, urine, CSF cultures
• True + vs. contaminant - Determined based on tx
Time to Detection of Bacterial
Cultures in Infants Aged 0-90 days
• CNMC:
– BCx: checked q10min, alarm if +  gram stain, team
called
• First subsequent read at 16-18 hours, then q24h
– CSF cultures
• Goal gram stain within 1 hour
• First time to check culture: 16-18 hours, then q24h
– Urine cultures
• First read at 16-18 hours, then daily
– Can call at night and ask someone to check if still neg
Time to Detection of Bacterial
Cultures in Infants Aged 0-90 days
• Results
– 2092 blood cultures; 101/115 + blood cultures
included in analysis
• 97% true pathogen (n=38) Bcx grew in 36h
– 2283 urine cultures; 192/232 + urine cultures
included in analysis
• 95% true pathogen (n=111) Ucx grew in 36h
– 1159 csf cultures; all 14+ included in analysis
• 86% true pathogen (n=7) CSFcx grew in 36h
UTI Length of Treatment in Infant
• 3mo F with fever found to have UTI
– Admitted on Ceftriaxone
P: Infants admitted with UTI
I: Transition to oral antibiotics after 3d
C: versus longer IV therapy
O: Treatment failure
Length of Intravenous Antibiotic
Therapy and Treatment Failure
in Infants with Urinary Tract
Infections
Patrick W. Brady, Patrick J. Conway and
Anthony Goudie
Pediatrics 2010; 126; 196
DOI: 10.1542/peds.2009-2948
Length of IV Abx Therapy in Infants with UTI
• Objective:
– To assess short (<=3d) v long (>=4d) IV abx therapy
and treatment failure in infants <6mo admitted
with UTI
• Treatment failure = readmit within 30d
• Methods:
– Retrospective cohort, infants <6mo admitted to 24
children's hospitals over 5y with UTI or pyelo
(PHIS)
• Excluded kids w complex conditions
Length of IV Abx Therapy in Infants with UTI
• Results: 12,333 kids met inclusion criteria
– Male gender, neonatal status, black, Hispanic, nonprivate insurance, known bacteremia, GU abnormality
– inc likelihood of receiving IV abx
Length of IV Abx Therapy in Infants with
UTI
• Results
– Treatment failure overall: 1.9%
• 1.6% in short-course, 2.2% in long-course
– Ie maybe sicker pts got long iv abxs and more likely to fail
• Outcome by pt characteristic and length of IV abx
» ie gender, age by 1month intervals, race, bacteremia, GU
abnormality)
– Only GU abnormality and severity of illness associated w
treatment failure
– Multivariate adjustment (addressed confounders ie
severity of illness) – no association between
treatment group and outcome
Osteomyelitis
• 10y male admitted for fever, L foot pain
– MRI confirmed evidence of osteomyelitis
– Patient started on Clinda IV
P: In patients with osteomyelitis
does
I: Early transition to PO Abx
C: Versus prolonged IV therapy
O: Affect clinical outcomes?
Prolonged Intravenous Therapy Versus Early Transition to Oral Antimicrobial
Therapy for Acute Osteomyelitis in Children
Theoklis Zaoutis, et al. Pediatrics 2009; 123;636
DOI: 10.15442/peds.2008-0596
Prolonged Intravenous Therapy Versus Early Transition to Oral Antimicrobial
Therapy for Acute Osteomyelitis in Children
Theoklis Zaoutis, et al. Pediatrics 2009; 123;636
DOI: 10.15442/peds.2008-0596
Prolonged IV Therapy Versus Early
Transition to PO for Osteomyelitis
• Objective: Compare the effectiveness of early
transition from IV to PO for acute, uncomplicated
osteo
• Methods: Retrospective cohort study (PHIS)
– Children aged 2m-17y dx with osteo between 20002005 at 29 free-standing children’s hospitals
• Results:
– 1o outcome: Tx failure (readmission w/in 6m)
– 2o outcome: Readmit w/in 6m for line complication,
adverse drug rxn, C. Diff, agranulocytosis
Prolonged IV Therapy Versus Early
Transition to PO for Osteomyelitis
Results: 1021 prolonged IV, 948 PO
• Overall readmission rate significantly higher in
prolonged IV group (10% vs 6%, p= 0.017)
• 1o outcome
– 5% for prolonged IV group; 4% PO group
– No significant association btw Tx failure and mode Abx
therapy
• 2o outcome
– Prolonged IV therapy group more likely to experience
Tx-related complication
• 3% readmitted for catheter complications, 1.6% for Abx
complications (vs 0.4% in PO group, p= 0.005)
GERD
• 2m FT male admitted for persistent emesis
with feeds associated with back arching,
fussiness
– Pt growing appropriately
– Work-up only reveals reflux
GERD
• 2m FT male admitted for persistent emesis
with feeds associated with back arching,
fussiness
– Pt growing appropriately
– Work-up only reveals reflux
Are there risks
associated with empiric
acid suppression
treatment of infants
and children suspected
of having GERD
Erica Y. Chung and Jeremy
Yardley
Hospital Pediatrics 2013;3;16
DOI: 10.1542/hpeds.2012-0077
Are there risks associated with acid
suppression therapy?
• Objective: Evaluate the potential serious
adverse effects associated with acid
suppressive meds in the pediatric population
• Methods: PubMed search
– Ages 0-18y; placebo-controlled or comparisons
with a nonacid suppression arm
• Results: 14 studies included
– NICU, PICU, non-critical care
Are there risks associated with acid
suppression therapy?
Results
• NICU
– Increased risk NEC, sepsis/bacteremia
• PICU
– Mixed results on VAP
• Non-critical care
– Increased rate PNA, LRTI, gastroenteritis
– Associated with C. Diff associated disease
Bronchiolitis
• 6wk female admitted with URI symptoms,
increased WOB and fever found to be RSV+
– Should she be evaluated for SBI?
P: In infants with bronchiolitis
I: Is testing for serious bacterial
infection
C: Compared to not testing
O: Indicated?
Risk of serious bacterial infection in young febrile infants with RSV infections
Levine D, et al. Pediatrics 2004; 113;1728-1734
DOI: 10.1542/peds.113.6.1662
Serious Bacterial Infections in Infants with RSV
• Methods: Multi-center prospective, cross-sectional
study (1998-2001)
– All febrile infants, aged 0-60d undergoing SBI eval
– RSV testing by antigen detection from NP swabs
• Results
– 1248 enrolled (22% tested + RSV)
– Overall SBI rate 11.4% (0.7% meningitis, 2% bacteremia,
9.1% UTI)
– RSV+ infants less likely to have SBI (7% vs 12.5%; RR 0.6)
Table 3. SBI by RSV Status
Serious Bacterial Infections in Infants with RSV
Results: Age-stratified
• <28d: Overall rate of SBI did not differ
significantly btw those who were RSV+ and
RSV- (10.1% vs 14.2%, RR 0.71, 95% CI 0.351.5)
• 29-60d: Overall rate of SBI was 5.5% (no
bacteremia or meningitis) with statistically
significant difference between RSV+ and RSV(5.5% vs 11.7%, RR 0.47, 85% CI 0.24-0.91)
HSV
• 20d male presenting with fever and irritability
– No maternal history of HSV
– Full SBI evaluation initiated
– Should HSV and empiric Acyclovir be done?
P: In infants presenting for
evaluation
I/C: What history/PE/labs are
associated
O: With HSV infection
HSV
• Methods: Retrospective case study of HSV
over 22y (1988-2009) period from single
institution
– Inclusion: infants <60d with final dx HSV
• Results:
– 32 cases included (25 confirmed, 7 probable); all
empirically tx w/ Acyclovir
– 75% of cases with CNS disease
HSV
• Results:
– 1.3% empirically treated infants ultimately
diagnosed with HSV
– 90% cases in infants <21d
– 50% presented w/ non-specific complaints
– 53% presented with fever, 13% hypothermia
– HSV meningitis: 1/3 had <20 WBC in CSF
– Except in disseminated disease, routinely obtained
labs were not distinctive in HSV-infected infants
Pneumonia
• 4yo M admitted with cough, fever, hypoxia
and CXR with RML infiltrate
– What is the evidence to support the 2011 IDSA
guideline to use Ampicillin as first-line therapy for
CAP?
P: In children hospitalized with communityacquired PNA
I: Does treatment with narrow-spectrum Abx
(i.e: Ampicillin)
C: Compared to broad spectrum (i.e: 3rd
generation cephalosporin)
O: Have better clinical outcomes?
Narrow vs broad spectrum antimicrobial therapy for children
hospitalized with PNA
Williams DJ, et al.* Pediatrics 2013; 132;e1141-8
* Kavita Parikh, CNMC
DOI: 10.1542/peds.2013-1614
Narrow vs Broad Spectrum Abx Tx for PNA
• Methods: Retrospective cohort study; 42
children’s hospitals btw 2005-2011 (PHIS)
– Included children aged 6m-18y hospitalized >2d
– Excluded potentially severe PNA, pts at risk for
healthcare assoc infections, pleural
drainage/PICU/mech vent within first 2 days
• Results:
– 1o outcome: LOS
– 2o outcome: PICU, 14d readmission, costs
Narrow vs Broad Spectrum Abx Tx for PNA
• Results: 15,564 children included
– 89.7% broad-spectrum, 10.3% narrow-spectrum
• No significant difference in LOS btw groups (when
adjusted for confounders)
• No significant difference in PICU admits, 14d
readmissions
• No significant difference in sub-analysis of
wheezers
• No significant difference on costs (adjusted
analysis)
Runners Up…
•
Biondi et al. Treatment of Mycoplasma Pneumonia: A Systematic Review. Pediatrics,
2014; 113; 1081.
•
Starmer et al. Rates of Medical Errors and Preventable Adverse Events Among
Hospitalized Children Following Implementation of a Resident Handoff Bundle
(IPASS). JAMA, 2013; 310(21): 2262-2270.
•
Mussman et al. Suctioning and Length of Stay in Infants Hospitalized with
Bronchiolitis. JAMA Pediatrics, 2013; 167(5): 414-421.
•
Fernandes et al. Glucocorticoids for Acute Viral Bronchiolitis in Infants and Young
Children. Cochrane Database Syst Rev. 2013; 6: CD004878.
•
Salo et al. Childhood Urinary Tract Infections as a Cause of Chronic Kidney Disease.
Pediatrics. 2011; 128(5): 840-847.
•
Ralston et al. Occult Serious Bacterial Infection in Infants Younger than 60 to 90 Days
with Bronchiolitis: a Systemic Review. Arch Pediatr Adolesc Med. 2011;
156(10):951-956.
Next Session: March 2015
• Review Guidelines:
– 2006 AAP Bronchiolitis Guidelines
– 2011 IDSA PNA Guidelines
– 2011 IDSA UTI Guidelines
– 2004 AAP Kawasaki Endorsed Clinical Report
– 2011 IDSA MRSA Guidelines